Contact Person:
Margarita Torres
Human Resources
hr@bridgeportchc.org
(203) 696-3260 x 3345 or 3388 or 3384

Click here for printable Employment From

 

Equal Access to programs, services, and employment is available to all persons. Those applications requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Position(s) applied for:
Date of Application:
Referral Source:
Advertisement Employee Relative
Government Employment Agency Walk-in
Private Employment Agency Other
 
Personal Information

First Name:

Last Name:
Address:
Street: City:
State: Zip Code:
Telephone #: Mobile:
Social Security #
If necessary, best time to call you home is
May we contact you at work?
If yes, work number and best time to call
If you are under 18 and it is required, can you furnish a work permit?
If no, please explain

Have you submitted an application here before?

If yes, give date(s)
Have you ever been employed here before?
If yes, give dates
Are you legally eligible for employment in this country?
Date available for work
Type of employment desired
Will you relocate if job requires it?
Are you able to meet the attendance requirements of the position?
Will you work overtime if required?
If no, please explain
Have you ever been bonded?
Have you been convicted of a cr ime in the last seven (7) years?
If yes, please explain
 
Employment History
Provide the following information for your past and current employers, assignments or volunteer activities, starting with the most recent (use additional sheets if necessary). Explain any gaps in employment in comments section below.
Employer:
Telephone
Address
Job Title
Immediate Supervisor and Title
Reason for Leaving
May we Contact for Reference? Yes No Later
Dates Employed
From:
To:
Starting Salary: Ending Salary:
Summarize the type of work performed and job responsibilities
Employer: Telephone
Address
Job Title
Immediate Supervisor and Title
Reason for Leaving
May we Contact for Reference? Yes No Later
Dates Employed
From:
To:
Starting Salary: Ending Salary:
Summarize the type of work performed and job responsibilities
Employer: Telephone
Address
Job Title
Immediate Supervisor and Title
Reason for Leaving
May we Contact for Reference? Yes No Later
Dates Employed
From:
To:
Starting Salary: Ending Salary:
Summarize the type of work performed and job responsibilities
Comments- Including explanation of any gaps in employment
Skills and Qualifications - Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.
Educational Background:
A. List last three (3) schools attended, starting with most recent.
B.List number of years completed.
C. Indicate degree or diploma earned, if any.
D. Grade Point Average or Class Rank.
E. Major field of study.
F. Minor field of study. (if applicable).
References
List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
Name
Telephone
Years Known
Additional Information
List professional, trade, business, or civic associations and any offices held.
Exclude memberships which would reveal sex, race religion, national origin, age,color, disablity or any other similarly protected status.
Organization
Offices Held
List special accomplishments, publications, awards, etc.
Exclude information which would reveal sex, race, religion, national origin, age, color, disabilty or other protected status.
List any additional information you would like us to consider

I understand that if I am employed, any misrepresentation or material omission made my me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employers's service, whenever it is discovered.

I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information.

The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employement for any specified period of definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer.

I understand it is this company's policy not to refuse to hire a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.
   
Name: Date: